Nephrogenic adenoma of the bladder: urographic spectrum

Nephrogenic adenoma is a rare, proliferative response of urothelium to urinary infection or injury of the bladder mucosa. Histologically, the lesion resembles proximal tubules of the nephron. While it can occur throughout the urinary tract, it usually appears in the bladder, with diverse radiographic manifestations. Of 6 patients with nephrogenic adenoma of the bladder, 3 presented with masses in the bladder and 2 with irregularities of the bladder mucosa on urography, while 1 showed no focal urographic abnormalities. There were no distinctive radiographic features of nephrogenic adenoma that would allow it to be differentiated from tumor or other inflammatory lesions. Although it is considered benign, bladder involvement may be extensive and eradication of the tumor may be difficult.     

Nephrogenic adenoma of the bladder: Urographic spectrum

Nephrogenic adenoma is a rare, proliferative response of urothelium to urinary infection or injury of the bladder mucosa. Histologically, the lesion resembles proximal tubules of the nephron. While it can occur throughout the urinary tract, it usually appears in the bladder, with diverse radiographic manifestations. Of 6 patients with nephrogenic adenoma of the bladder, 3 presented with masses in the bladder and 2 with irregularities of the bladder mucosa on urography, while 1 showed no focal urographic abnormalities. There were no distinctive radiographic features of nephrogenic adenoma that would allow it to be differentiated from tumor or other inflammatory lesions. Although it is considered benign, bladder involvement may be extensive and eradication of the tumor may be difficult.     

Nongynecologic bladder and perivesical ultrasound

Ultrasound is effective in evaluating pathologic entities in and around the urinary bladder. Abnormalities may be classified into 2 groups: lesions primarily affecting the bladder, including the bladder wall; and perivesical lesions, which secondarily affect the urinary tract. Intrinsic bladder diseases include inflammatory lesions, stones, and tumors, both primary and metastatic. Extrinsic perivesical abnormalities include lesions of the prostate, seminal vesicles, urethra, rectum, and perivesical soft tissues. Since the bladder is routinely visualized on pelvic ultrasonography, awareness and recognition of the ultrasonic appearance of disease in and around the urinary bladder can lead to more accurate diagnosis and detection of unsuspected disease.     

Spiral-CT with multiplanar reconstructions (MPRS) in the evaluation of ureteral neoplasms: preliminary results

PURPOSE: Urothelial tumors of the upper urinary tract (renal pelvis and ureters) are rare: the most common of these are Transitional Cell Carcinomas (TCC), usually localized in the bladder (75% of cases), whereas only 7-10% arise in the renal pelvis and 2,5-5% in the ureter. Multicentricity is not infrequent and synchronous or metachronous tumors have been reported to develop in 11-13% of patients with upper urinary tract cancer and 2-4% of those with bladder cancer. The presence of additional lesions can change patient management. Clinically these tumors may present with hematuria or flank pain, but sometimes there are no specific clinical findings. Radiological studies play an important role in tumor detection and staging and in follow up. The diagnosis is usually performed by IVU and US, while CT is generally employed in the staging. Our purpose was to verify the role of Spiral CT with Multiplanar Reconstructions (MPRs) in the evaluation of ureteral tumors. MATERIAL AND METHODS: Nine patients with ureteral neoplasms were examined with a single detector spiral-CT, using the following parameters: 120 kV, 200 mA; 5 mm collimation, pitch 1.4, slice reconstruction every 5 mm; image acquisition 2-5 minutes after injection of 120 cc of contrast medium (300 mgI/ml). All the exams were transferred to a separate workstation to obtain curvilinear MPRs. RESULTS: Spiral CT on the axial plane visualized 4 urothelial tumors as concentric ureteral wall thickening; 3 as intraluminal soft tissue masses, with involvement of almost the entire urinary tract, as far as the bladder in 1 case. In other 2 patients there were synchronous lesions which presented both patterns (wall thickening and intraluminal mass). In all cases the lesions exhibited moderate enhancement after c.m. injection. Medium- to high-grade hydronephrosis above the tumors was always present. On MPRs both ureteral involvement and dilated, urine-filled upper urinary tract were clearly represented on coronal and sagittal oblique planes; these images allowed to visualize the craniocaudal extension of short or long lesions, and to detect multicentricity. DISCUSSION: The radiological diagnosis of ureteral tumors is usually performed by IVU, US and CT. IVU allows to visualize the tumors as filling defects or irregular narrowing of the ureteral lumen. IVU however is unable to show the real extent of the tumor in obstructive disease or in nonfunctioning kidney. US visualizes the lesion as an echoic mass in the lumen, although it is sometimes difficult to differentiate neoplastic lesions from other filling defects and to visualize the entire ureteral tract. CT is generally employed in the staging of ureteral tumors. CT findings are usually very useful for distinguishing ureteral neoplasms from other filling defects based on their attenuation and enhancement characteristics. Spiral CT with MPRs allows to obtain panoramic views of the urinary tract; these images are more effective than those of IVU, because of their capability to show the longitudinal extension of the lesion and the presence of multicentric tumors. Furthermore with MPRs it is possible to visualize the ureteral tract distal to the lesion, overcoming the limitations of IVU in nonfunctioning kidney or obstructive disease. CONCLUSIONS: Spiral CT with MPRs is useful in the evaluation of ureteral tumors as it is capable of visualizing the whole extension of the lesion and the presence or absence of multicentric lesions, which can change patient management.     

Multidetector computed tomography urography (MDCTU) for diagnosing urothelial malignancy

Multidetector computed tomography (MDCT) is well established for the detection of stones and renal masses, but more recently MDCT urography (MDCTU) is becoming widely used for examination of the entire urinary tract aimed specifically for diagnosing urothelial lesions. Evidence is rapidly accumulating to support the use of MDCTU in this manner. Familiarity with the MDCTU signs of urothelial malignancy is a prerequisite for optimum radiological practice. This article provides a review of the appearances of transitional cell cancer in the upper urinary tract and bladder.     

经阴道超声诊断女性下泌尿路病变的价值

目的:探讨经阴道超声(TVUS)诊断女性下泌尿路病变的价值。材料和方法:对48例已婚女性下泌尿路病变患者,采用TVUS观察病变特点,超声检查结果与临床病理结果对照分析。结果:本组共发现输尿管病变20例,膀胱病变24例,尿道病变4例,其中诊断输尿管病变TVUS诊断率为100%(20/20),可以更清晰显示输尿管肿物的血供情况和输尿管异位开口;对膀胱三角区病变的观察,在显示病变位置、形态、血流分布特点等细节方面,TVUS比TAUS清晰。TVUS还有助于盆腔囊性病变与输尿管和膀胱关系的判断。诊断尿道病变以TVUS观察更准确。结论:对女性输尿管下段病变和膀胱三角区和尿道病变,应用TVUS可以提高超声诊断的正确率。     

Virtual cystoscopy of bladder neoplasms. Preliminary experience]

PURPOSE: We investigated the comparative sensitivity of virtual and conventional cystoscopy in patients with urinary bladder cancer. MATERIAL AND METHODS: Twelve patients (8 men and 4 women; mean age: 61 years, range: 49-73) with findings of bladder cancer at conventional cystoscopy were submitted to volumetric spiral CT of the urinary bladder. Before the examination, the urinary bladder was distended with 180-200 mL of air. CT findings were then sent to an independent workstation to generate interactive intraluminal views of the bladder. The findings of virtual cystoscopy were compared with those of conventional cystoscopy in 11 patients and with the findings of transurethral resection after urethrotomy in one patient. All lesions had pathologic confirmation. RESULTS: Eighteen (90%) of 20 masses detected on conventional cystoscopy were visualized with virtual cystoscopy. The latter allowed readers to identify 13 of 13 masses (100%) > 1 cm and only 5 of 7 (71%) < 1 cm; three 4-mm masses were missed. Although only a subjective evaluation of lesion size was possible on conventional cystoscopy, there seemed to be good agreement on mass size and site with both techniques. DISCUSSION: Cystoscopy plays a key role in the diagnosis of urinary bladder carcinoma. However cystoscopy is invasive, has a limited field of view and lacks an objective scale; moreover, it is not indicated in patients with severe urethral strictures or active vesical bleeding. In our study, virtual cystoscopy depicted all the masses > 1 cm, and a lesion in a diverticulum with a small opening. Virtual cystoscopy was also very useful in a patient with urethral stricture (who could no be submitted to conventional cystoscopy) where it showed the lesion before transurethral resection after urethrotomy. The virtual technique could also be complementary to conventional cystoscopy in evaluation of bladder base and anterior bladder neck, as well as for postchemotherapy follow-up. Unfortunately virtual cystoscopy does not allow biopsy of suspicious lesions.     

Early diagnosis of congenital ureterocele]

Ureterocele is a congenital urinary abnormality characterized by the presence of an intrabladder hernia or cystic ballooning of the lower end of an ureter lying between the mucosa and muscle of the bladder. The abnormality leads to urinary retention and recurrent urinary tract infection which can cause irreversible damage to the kidney. It can become very large and is the most common cause of bladder outlet obstructions in infant girls. It may be associated with serious urologic abnormalities in either sex. This abnormality can be suspected in the fetus by ante-natal echography and confirmed by other X-ray investigations after birth.     

Evaluation of 18F-FDG PET with bladder irrigation in patients with uterine and ovarian tumors.

The purpose of this study was to evaluate PET using (18)F-FDG for gynecologic lesions with continuous bladder irrigation to eliminate artifacts from the (18)F-FDG activity in the bladder. METHODS: Forty-one patients were studied. They had 23 cervical uterine lesions (15 cases of cancer, 5 recurrences, 3 nonrecurrences); 8 cases of uterine corpus cancer, including 2 recurrences; and 10 ovarian masses (6 malignant, 4 nonmalignant). All cases of cancer were histologically proven; however, 2 cases of nonrecurrent uterine cervical carcinomas were diagnosed by clinical course. Continuous bladder irrigation was performed 35-55 min after intravenous administration of 185-370 MBq (18)F-FDG, and an emission scan was obtained 40-55 min after intravenous administration. Standardized uptake value (SUV) was used to estimate the degree of (18)F-FDG uptake quantitatively. RESULTS: After bladder irrigation, the (18)F-FDG activity in the urinary tract was eliminated in 33 patients, so that detection of tumor (18)F-FDG accumulation was easy. Two patients showed residual activity in the urinary bladder, and 6 patients showed activity in the ureter. An artifact was seen in 1 patient with residual activity in the urinary bladder caused by insufficient irrigation. However, these residual activities had no influence on detecting (18)F-FDG accumulation in tumor. The mean (+/-SD) of SUVs of malignant lesions was 6.04 +/- 3.22, that of nonmalignant lesions was 1.71 +/- 1.12, and the difference was significant (P = 0.0002). SUVs of all malignant lesions were greater than 2.0, and SUVs of all nonmalignant lesions, except the 1 case of ovarian fibroma, were less than 2.0. CONCLUSION: (18)F-FDG PET with continuous bladder irrigation is useful for eliminating (18)F-FDG activity in the bladder and for differentiating between malignant and nonmalignant uterine or ovarian masses.     

Urinary tract involvement from pancreas carcinoma

Pancreas carcinoma is sometimes notoriously difficult to diagnosis. It is well known that pancreas carcinoma can invade contiguous organs, but no attention for urinary tract involvement is paid. Urinary tract is involved at a late stage but may represent the first symptomatic evidence of disease. In such case, pancreas carcinoma can be presented initially as urologic disease and patients' symptom may not be differentiated from urinary tract disease. Computed tomographic (CT) images and medical records of 50 patients with histologically proved pancreas carcinoma were reviewed. There were 10 cases with urinary tract involvement. Those of 8 were male and 2 were female. There was a high incidence of left urinary tract involvement (left:right:bilateral = 7:2:1). Although 9 cases were pancreas body and tail carcinoma, 1 case was pancreas head carcinoma. And those stages were all in IV. All cases have confirmed evidence of urinary tract involvement at autopsy within 4 months following CT studies. IVP study was performed in 8 of these cases. We compared those IVP, CT images and findings of autopsy. In those patients, 4 cases showed direct invasion of the kidney, 5 cases showed ureteral involvement and 1 case showed metastasis to the urinary bladder and ureters. IVP showed inferior displacement of the kidney and/or ureteral displacement on the affected side. And also, collecting system distortion was demonstrated, including hydronephrosis secondary to ureteral compression. CT scan showed abnormal mass which is contiguous to the pancreas, showing compression the kidney and/or retroperitoneal extension with ureteral involvement. Metastasis to the urinary bladder is also identified. The findings of autopsy were almost the same of the CT findings. Pancreas carcinoma characteristically remains silent until little chance for cure. Although urinary tract involvement is rare, it can mimic renal and ureteral pathology. In differential diagnosis of urinary tract lesion, the disease process originated from pancreas should be included as well as from contiguous structures.     

Neurogenic bladder simplified

Neurogenic bladder dysfunction, if not properly diagnosed and treated, can lead to rapid deterioration of renal function by compromise of the upper urinary tracts. Two major categories of neurogenic bladder (detrusor hyperreflexia areflexia) have been discussed including the pathophysiology of the voiding dysfunction and the typical radiographic findings. Radiologists studying patients with suprasacral cord lesions should be aware of the causes, symptoms, and treatment of autonomic dysreflexia. Although video urodynamics is the state-of-the-art modality for evaluating complex or refractory neurogenic bladder, the practicing radiologist with an understanding of this condition can detect many radiographic changes in the lower urinary tract that suggest neurogenic dysfunction of various types.     

Roentgenologic abnormalities of the urinary bladder secondary to Crohn's disease.

Urinary tract symptoms and signs may result from secondary involvement of the urinary bladder in patients with Crohn's disease. In a small but significant proportion of these individuals, urinary tract symptoms represent the initial or predominant mode of presentation. Such patients may be erroneously treated for primary infection of the lower urinary tract for prolonged periods before the intestinal origin of the disease process is discovered. Roentgenologic abnormalities of the urinary bladder may provide early and important clues to the correct DIAGNOSIS. The various abnormalities of the urinary bladder which may occur secondary to Crohn's disease are described and illustrated, and the roentgenologic differential diagnosis is discussed.     

Morphology and diagnosis of acquired bladder deformities

Acquired displacements of the urinary bladder refer to intrapelvic pathological anatomy. These alterations of the bladder are predominantly detected via an initial radiologic study with intravenous urography or suprapubic pelvic ultrasonography. According to their clinical incidence displacements of the bladder can occur in: pelvic space-occupying lesions; displacements in musculo-fascial defects of supporting structures as well as in extirpation cavities of the small pelvis; extrapelvic space-occupying lesions. Herniation, prolapse and descensus of the bladder can be accurately diagnosed by correct examination via intravenous urography. The diagnostics of pelvic and extrapelvic pathogenetic causes require the complex application of all methods of diagnostic imaging, the value of which is determined by clinical diagnosis and by the choice of an appropriate therapy.     

Radiographic herald lesion of the urinary bladder: pictorial essay

At cystoscopy a focal mucosal abnormality may be indicative of a pathological process extrinsic to the urinary bladder and has been termed 'the herald lesion'. The aim of the present pictorial essay was to describe the radiographic counterpart to this cystoscopic finding. Radiographic herald lesions are shown in patients with extravesical inflammatory (Crohn's disease, colonic diverticulitis and pelvic inflammatory disease) and neoplastic (colon carcinoma) processes, and urinary tract complications of these conditions are described and illustrated.     

Funktionelle Störungen des unteren Harntrakts im Kindesalter

Functional disorders of the lower urinary tract as well as vesicoureteral reflux involved in the disease complex of urinary tract infection/permanent renal parenchymal damage can be considered predisposing or risk factors. Two main forms can be distinguished, i.e., unstable bladder and dysfunctional voiding, while transitional forms between the two exist. Functional disorders of the lower urinary tract obstruct spontaneous resolution of vesicoureteral reflux. They are found in about 50% of cases in all children with urinary tract infection and are associated with an increased risk of developing renal parenchymal scars. They are observed during the newborn period up to school age. In the first few months of life, particularly boys with bilateral high-grade reflux and congenital renal parenchymal damage are affected. At later ages girls are also affected, but in this age group bladder instability predominates. Incontinence as the leading clinical symptom appears in approximately 70% of all cases and is closely correlated with chronic constipation. Imaging procedures in addition to urodynamic methods are of decisive importance for diagnosis and treatment, but noninvasive approaches such as sonography should be given preference.     

The urinary tract image obtained during 99mTc bone scanning.

During the course of a technetium (99mTc) bone scan, it is usual to obtain an image of both kidneys and the bladder. A review of 96 bone scans performed over a two-year period was undertaken in an attempt to assess the accuracy of this image. Ten examinations showed abnormalities of the urinary image suitable for inclusion in the paper, and were subsequently further investigated. Three cases showed that relatively small lesions may be detected within a kidney if localised caliectasis produced a 'hot-spot'. However, greater diffuse concentration of the imaging agent within one renal image does not necessarily represent an abnormality. Space-occupying lesions can be detected as areas of diminished activity within the renal image, if the tumour is extensive. 'Defects' in the bladder image reflect extrinsic impression rather than intrinsic lesions. A further six cases are included to demonstrate how unusual accumulation of the imaging agent within the abdomen may mimic renal tract pathology.     

Incidental detection of urinary tract abnormalities with skeletal scintigraphy

Urinary tract abnormalities are detected as incidental findings in 15% of skeletal scintigraphic studies. Several scintigraphic patterns denote these abnormalities. Bilateral diffuse increased uptake is found in patients who have undergone chemotherapy and those with hyperparathyroidism, hypercalcemia, and sickle cell disease. Bilateral diffuse decreased uptake occurs in patients with end-stage renal disease, extensive metastatic disease to the bone, and various hematologic disorders. Focal increased activity is associated with postoperative changes and effects from radiation therapy. Focal decreased uptake is caused by space-occupying lesions such as abscesses, cysts, and neoplasms. Abnormal size, shape, and position associated with abnormalities of the kidney and bladder can also be seen. Although these scintigraphic patterns are seldom suggestive of a definitive diagnosis, they are highly specific for urinary tract disease.     

磁共振尿路成像临床应用

目的 探讨磁共振尿路成像(MRU)的临床应用价值。方法 利用PHILIPS T5-NT 0.5T超导型MR扫描机,采用快速自旋回波(TSE)序列重T_2加权技术,对52例患者作MR尿路成像,行最大信号强度投影(MIP)处理,所有患者均先行常规MR扫描。结果 52例中,尿路梗阻扩张26例,其中:肾盂-输尿管交界段狭窄7例,输尿管癌4例,输尿管结石6例,输尿管炎性狭窄4例,输尿管外压1例,膀胱癌2例,神经源性膀胱2例。MRU显示尿路梗阻扩张正确率达100％,对梗阻定性诊断有3例错误。无尿路梗阻17例,其中肾癌3例,肾盂癌2例,肾血管平滑肌脂肪瘤1例,肾囊肿9例,马蹄肾1例,一侧肾缺如1例,均由MRI和MRU相结合确诊。另有9例患者呈现不同程度肾盂积水,未见尿路梗阻征象,其中:6例结合临床诊断为肾盂肾炎。52例中,部分病例与B超、IVU、CT扫描结果进行了比较。结论 MRU为一有效安全无创的影像检查技术,特别适用于肾功能不良和有IVU禁忌症者,对确定尿路梗阻扩张,梗阻的定位、定性有重要的应用价值。MRU和MRI相结合能对泌尿系统疾病的诊断提供更为完整的诊断依据。但在实践中,应依据患者具体情况合理选用MRU检查。     

Urinary bladder tumors studied by cystosonography. Part I: Detection

Findings of excretory urography, the principal screening test for bladder tumors, do not accurately depict these tumors. In an attempt to assess the value of sonography in detecting bladder lesions, we used suprapubic sonography to examine 120 patients who presented with various lower urinary tract symptoms. Commercially available equipment was used. Ultrasound detected 16 of the 17 cases of bladder tumor that were confirmed by cystoscopy. In 14 of these, satisfactory images were obtained. Nontechnical factors that affect detection include size and location of the tumor, bladder distention, obesity of the patient, and the operator's skill. Blood clot, benign prostatic hypertrophy, cystitis, and bladder trabeculae can mimic bladder tumors. Sonography may be helpful as an initial screening test for patients suspected of having bladder tumors; however, further experience is needed before conclusions can be made.     

Lower urinary tract trauma.

Twenty-eight patients with lower urinary tract injuries were reviewed at H?tel-Dieu de Montréal. Eighteen involved the urethra and ten involved the bladder. Pelvic rami fractures are the main cause of bladder rupture, including almost all cases of extraperitoneal bladder rupture. Pelvic fractures are also the main cause of posterior and bulbo-menbranous urethra rupture. Endoscopy and indwelling catheter insertions follow in importance. Rupture of the bladder can be either extraperitoneal (80%) or intraperitoneal (20%). Ruptures of the urethra involve mainly the posterior and bulbo-membranous segments of the urethra. Post-traumatic strictures nevertheless affect the anterior segment more commonly. In all suspected cases of injury involving the lower urinary tract, retrograde urethrography should be done first, followed by retrograde cystography if indicated. A good knowledge of the relationship of the anatomic compartments is essential to the assessment of communicating injury.